GW1-2022-09543_Well Construction - GW1_20221014

\ 1
„ r,?-L CONST1F�'.1UCTION I ECORD QW-fig For Internal Use Only:
1.Well Contractor Informntion:
le o w h 14.WATER ZONES �
Well Contractor Name &J� FROM TO DESCRIPTION
F1 ��303�� � 66 ads ft. �46 f
`i ft 9 ft
NC Well Contractor Certification Number
15.OUTERCASING(for aiulfi-rased' cells ORLINE,R d•a licable
YADKIN WELL COMPANY,INC. FROM To 33 TEaCKAESS MATE
WAL
ia.
CompaayNeme ft.
16,INNER CASIlVG OR TUBII�sG eothermal closed-loo )
2.Well Construction Permit#: FROM TO DIAMETER closed-lou MATERIAL
Liss all applicable well constructfon permits(le UIC,Cawty,Slate,Variance,.4 ft 'y ft P� in. SAP,
3.Well Use(checkwell use): ft r ft L^ in.
Water Supply Well: 17.SCREEN
FROM To DIAMETER SLOT SIZI: :THICHMSS MATERIAL
❑Agricultural ❑Municipal/Public it. ft.
❑Geothermal(Heating/Cooling Supply) �dtesidential Water Supply(single) t, ft.
m °
❑Tndustrial/ComeIcial ❑Residential Water Supply(shared);.; 18.GROUT
01nigation ❑Wells>100,000 GPD FRO TO AIATERIAI. EMPLACEMENTAILTHOD&AMOUNT
Non-Water Supply Well: ft ft. LAW A c 6 �
❑Monitoring ❑Recovery `' ft ft
Injection Well:
❑Aquifer Recharge ❑Groundwater Remediation ft, %
:19
❑Aquifer Storage and Recovery CiSalinity'Barrier •SAND/GRAVEL PACK applicable)
FROM TO MATERIAL / EMPLACEMENTMLTHOD
❑Aquifer Test ❑StDrmwater Drainage ft. R o
❑Experimental Technology ❑Subsidence Control ft it
❑Geothermal(Closed Loop) ❑Tracer' 20,DRILLINGLOGattach additional sheets ifnermsa
❑Geothermal eatln l'DOIIn Rehun []Other FROM TO DESCRIMON color,hardness,soiUrork e, size,ctL "t
CH g/ g ) (explain under#21 Remarks)
8 it. 149 ft.
4.Date Well(s)Completed: �° �' WeIII /�T# �'"7 i? l R. ft
Sa.Well Location: P .06
Ph ] X y kfC,"J �T-4i?el ft ft Facr'lity/Owner ame "`� F`` ID#(ifapplicable) ft ft
i•
ZI-5-. C�� lyt� �Q ,. . 0'h " ft ft
Physical Address,city,and zip ft ft.
��• ' _ _ , � on-,;:�, ��a :,..,•-.�,.-•.. ,,� unit '
a,v�e-
21.REMARKS
County :` Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seegrids 6 decimal degrees:
(ifwell field,one lathong is sufficient)
9 22.Certification: ;t
N. t
6.Is(are)the well(s):Oermanent- or ❑Temporary r re of a ed e C n ',Date
By 1' trig tlnr ornr,]hereby cdrt"i tat the C (lts)was(were)constructed in aai;rdance with
7.Is this a repair to an existing well: ❑Yes or j*1�1) "f 15A1NCAC C.0100 a 15A NCAC 02C.O DO lEell Constriction Standni ds rni'that a copy
If this is a repair,fdl our known well construction information and explain the nature of the of thls rec rd has been provided to the we/!owner
repair 7mder-921 remarks section or on the back of thisform.
23.Site diagram or additionalwell details:
You may use the back of this a C..
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same Y pig to provide additional well cons�,;b ion info
construction,only 1 W-1 is needed, Indicate TOTAL NUMBER of welIs (add'See Over'in Remarks Box).You may also attach additional pages b,:'n.ecessary.
drilled l
24.SUBMITTAL INSTRUCTIONS ,
9.Total well depth below land surface:
For multiple wells list all depths fdifferent(erample-3©200'an 2Q100D Submit this GW-1 within 30 days of:well completion per the folio'wing:
24a. For All Wells: Original form Ito Division of Water Resources WR,
1D.Static water level below top of casing:_ _� � ft, (D )
Ifwater level is above casing,use"+" ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
i
(O Bit Of.. 24b.For Infection Wells:'Copy• 11:Borehole diameter: (in.) - py to DWI;,Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AIR ROTARY
('. , g tary,cable,direct push,etc. 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
I e auger,,ro p ) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY- Copy WR,CCPCUA
24d.For Water Wells producing over 100,000 GPD•Co to D
13a.Yield(gpm) Method of test: a t ale Permit Program,1611 MSC,Raleigh,NO 27699-1 6 7 1
13b.Disinfection type: 70%HTH Amount: 71 49 OZ DATE SITE VISITED: ZZ
Pr--- — VISITED BY: 113